Driver/Vehicle Declaration

DRIVER / VEHICLE DECLARATION – Due to changes in Duty Of Disclosure, we require that you complete this form at renewal of your motor vehicle policy.

If you answer ‘yes’ to any of the questions about the registered owners or nominated drivers, you must provide details.   If you answer ‘no’ to roadworthiness, or ‘yes’ to modifications, you must also provide details.

QUESTIONS ABOUT THE REGISTERED OWNERS & NOMINATED DRIVERS

In the last 12 months, has the registered owner or any nominated driver:

Had a motor accident or loss, a vehicle burnt or stolen or made a claim under a motor insurance policy? (regardless of whom was at fault). *

Had a speeding fine and/or any other motoring conviction or prosecution including camera offences but excluding parking infringements? *

Had their licence cancelled, suspended or special conditions imposed? *

Had any insurance declined or cancelled, been refused renewal of any insurance, had special terms, conditions or excesses imposed, or had a claim refused? *

Had a conviction for driving under the influence of alcohol or drugs? *

Has the registered owner or any nominated driver ever: Been convicted of or had any fines or penalties imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property? *

Been declared bankrupt and not been discharged within the last 12 months? *

Suffer / suffered from any physical or mental disability or medical condition or are any dependent on any drug or medication which could affect their driving performance? *

Been convicted of or had any fines or penalties imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property? *

Is the vehicle roadworthy? *

Has the vehicle had any modifications? *

14 + 14 =